2 nd Notice AHCCCS Insurance Requirements ACTION REQUIRED September 29, 2014 Page 1 of 5

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1 Dear Providers and Staff: 2 nd Notice ACTION REQUIRED September 29, 2014 Page 1 of 5 We distributed a blast fax communication to you on July 16 explaining that effective October 1, 2013 AHCCCS updated its Minimum Subcontract Provisions to include additional insurance requirements and Care1st is required to verify adherence to these insurance requirements. Following that communication we received questions and comments from many of you. Many of you also submitted insurance information thank you! Based on your questions and the fact that most of the insurance information we ve received does not fully meet the AHCCCS requirement, we created the attached checklist we hope will be helpful. We know these changes are confusing and we want to do everything we can to be clear and minimize additional work on your part. Please review and complete the attached checklist and return it along with Certificates of Liability with required coverage levels, endorsements and waivers to via fax at or via to PNOaz@care1st.com by 10/31/2014. This communication also outlines the additional insurance requirements and provides examples to assist you. Once you review, if you have questions, please call us! The AHCCCS insurance requirements include Commercial General Liability, Business Automobile Liability and Worker s Compensation and Employers Liability. Your commercial general liability policy and your business automobile policy (if applicable), need to include an endorsement (see letter a. below under Commercial General Liability and letter a. below under Business Automobile Liability) and a waiver of subrogation (see letter b. below under Commercial General Liability and letter b. below under Business Automobile Liability) in the Description field of your policy. Your worker s compensation and employers liability policy requires only the waiver of subrogation language (see language under this section on page 2). Outlined below are the minimum requirements. Policy examples follow. Commercial General Liability Occurrence Form Policy should include bodily injury, property damage, personal and advertising injury and broad form contractual liability coverage. The amounts below are the minimum requirements. General Aggregate $2,000,000 Products Completed Operations Aggregate $1,000,000 Personal and Advertising Injury $1,000,000 Damage to Rented Premises $50,000 Each Occurrence $1,000,000

2 Page 2 of 5 a. The policy shall be endorsed (Blanket Endorsements are not acceptable) to include the following additional insured language: The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees shall be named as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor." Such additional insured shall be covered to the full limits of liability purchased by the Subcontractor, even if those limits of liability are in excess of those required by this contract. b. Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements are not acceptable) in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Business Automobile Liability Bodily Injury and Property Damage for any owned, hired, and/or non-owned vehicles used in the performance of the services under contract. The amount below is the minimum required. Combined Single Limit (CSL) $1,000,000 a. The policy shall be endorsed (Blanket Endorsements are not acceptable) to include the following additional insured language: The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees shall be named as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor, involving automobiles owned, leased, hired or borrowed by the Contractor." Such additional insured shall be covered to the full limits of liability purchased by the Subcontractor, even if those limits of liability are in excess of those required by this contract. b. Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements are not acceptable) in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Worker s Compensation and Employers Liability Workers' Compensation Statutory Employers' Liability Each Accident $500,000 Disease Each Employee $500,000 Disease Policy Limit $1,000,000 Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements are not acceptable) in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Two examples for your reference are included on page 3 and 4: 1. Commercial General Liability and Business Automobile Liability includes limits, endorsement and waiver of subrogation language 2. Worker s Compensation and Employers Liability includes limits and waiver of subrogation language We are required to verify your adherence to these insurance requirements. We appreciate you submitting Certificates of Liability with required coverage levels, endorsements and waivers along with the attached checklist to Provider Network Operations via fax at or via to PNOaz@care1st.com. We are asking that you provide us the certificates by 10/31/2014. Please call with any questions at the number below.

3 Page 3 of 5 Commercial General Liability and Business Automobile Liability Example: AHCCCS minimum coverage limits Add AHCCCS as the Certificate Holder AHCCCS required endorsement language and waiver of subrogation language

4 Page 4 of 5 Worker s Compensation and Employers Liability Example: AHCCCS minimum coverage limits Only Waiver of Subrogation language is required for Worker s Comp policy Add AHCCCS as the Certificate Holder

5 Page 5 of 5 Check List FAX To: Fax To: From: Phone: Group: Date: Re: Prior to submitting your insurance information complete this checklist, use it as a tool to address everything that s required and send it on top of your insurance document(s). Commercial General Liability Business Auto Liability Worker s Comp Liability [REQUIRED] ATTACHED ATTACHED N/A ATTACHED N/A General Aggregate $2,000,000 Products Ops Aggregate $1,000,000 Personal & Adv. Injury $1,000,000 Damage to Rented Premises $50,000 Each Occurrence $1,000,000 Your document must address all of the above items and minimum amounts Combined Single Limit $1,000,000 Your document must address all of the above items and minimum amounts Each Accident $500,000 Disease Each Employee $500,000 Disease Policy Limit $1,000,000 Your document must address all of the above items and minimum amounts Endorsement Required for Commercial General and Business Auto Liability The policy shall be endorsed (Blanket Endorsements are not acceptable) to include the following additional insured language: The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees shall be named as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor." Such additional insured shall be covered to the full limits of liability purchased by the Subcontractor, even if those limits of liability are in excess of those required by this contract. Waiver of Subrogation Required for all The policy contains a waiver of subrogation endorsement (Blanket Endorsements are not acceptable) in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the